Headaches – USMLE Exams

by / Friday, 25 June 2010 / Published in Internal Medicine

Migraine: 60% are unilateral, often triggered by: cheese, caffeine, menses, OCP’s

Do a CT or MRI if HA has any of the following:

  • Sudden and/or severe
  • Onset after 40yr
  • Associated with any neurological findings
  • May be preceeded by an aura and/or scotomata (Dark spots in visual field), and abnormal smells

Treatment:

  • The best initial abortive therapy is sumatriptan or ergotamine
  • Prophylactic therapy takes 4-6wks to work, if patient gets four or more HA per month, prophylax with propranolol.
  • Alternate prophylactics with CCBs, TCA’s, or SSRI.

Cluster Headaches: 10x more frequent in men than women.  Are exclusively unilateral w/ redness and tearing of the eye and rhinorrhea.

Treatment:

  • The best abortive therapy is 100% 02.
  • This treatment is unique to cluster HA’s.
  • Sumatriptan can also be used in same way as is in migraines.

Prophylactic therapy: there is none because these HA’s are numerous but short and intense, and the “cluster” would be over by the time the prophylaxis kicked in.

HA Type MIGRAINE CLUSTER
Gender Men 10x more than women
Presentation Unilateral or bilateral, aura Only unilateral, tearing/redness of eye
Abortive Sumatriptan Sumatriptan, Special: 100%02
Prophylactic Propranolol none

* Sumatriptan is similar to 5HT, and works by causing vasoconstriction in cerebral arteries.

Temporal Arteritis

Patient will present with tenderness over the temporal area and may also complain of jaw claudication

Diagnosis:

  • First check the ESR
  • The most accurate test is a biopsy of the temporal artery

Treatment:

  • Give steroids immediately, do not delay if this is suspected

Pseudotumor Cerebri

  • This presents most commonly in a younger woman with a headache and double vision, papilledema
  • CT/MRI show up normal
  • Vitamin A use is often the cause

Diagnosis:

  • LP is the most accurate test because it shows an elevated opening pressure

Treatment:

  • Involves weight loss

Acetazolamide can also be given

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